Myths, mandates, and decision-making: A qualitative exploration of COVID-19 vaccine hesitancy among pregnant and postpartum women in Pakistan

Background: Among pregnant and postpartum women, decision-making for receiving the COVID-19 vaccine is influenced by vaccine safety concerns, misconceptions, shifting vaccine policies, and exclusion in the initial vaccine rollout. This caused confusion and vaccine hesitancy among many groups including pregnant and postpartum women. Objective: The objective of this study was to understand the multilevel factors that influence vaccine decision-making among pregnant and postpartum women in Pakistan, which is crucial for improving vaccine demand among the vulnerable group—pregnant and postpartum women. Methods: This study is part of a multi-country mixed method study conducted in Brazil, Ghana, Kenya, and Pakistan. In Pakistan, fifty in-depth interviews were conducted with pregnant and postpartum women from two hospitals in Karachi. A grounded theory analysis approach was used, and a socio-ecological framework encompassing four levels of influence was applied to synthesize the study findings. Results: At the individual level, influences included concerns about vaccine safety, particularly regarding the health of the women and their babies due to potential side effects. Strong religious beliefs and trust in God also deterred some women from receiving the COVID-19 vaccine, as they relied on their faith practices. However, women with confidence in the vaccine had a positive attitude toward vaccination. At the interpersonal level, factors influencing vaccine decisions included the strong influence of observing others and recommendations from family and healthcare providers. Community-level factors included misconceptions about the vaccine's purpose and effects, and religious leaders' recommendations either supporting or discouraging vaccination. Policy-level factors involved mandatory vaccination for accessing public spaces, employment, and healthcare services. Coercive vaccination policies led some women to obtain vaccine cards without getting vaccinated. Conclusions: Efforts to promote vaccination among pregnant and postpartum women in Pakistan should engage family members, healthcare providers, and religious leaders, and implement evidence-based vaccine mandates to increase demand and to support uptake of maternal COVID-19 vaccination.